Physician Perspectives On Health IT

CMIO

An ambulatory electronic health record (EHR) can be provided to the physician practice through one of two different models:

Web-based-- also referred to as a "hosted EHR" or the "ASP Model" where the physician accesses the EHR through an Internet connection

Client-Server (C/S)-- the traditional model where the EHR server may physically resides in the physician's office

Both models are considered to be acceptable, but each has inherent pros and cons to consider. The traditional model of choice has been the “client-server” model. In this model the EMR software is installed on a server that is typically located in the physician’s office. The physician and staff access the EMR through computer devices that are connected to the server through a local area network (LAN) set up in the office. The computers may be connected wirelessly to the network if desired. This model has a few similarities to loading Quicken on your home computer and then using Quicken to pay bills online:

After loading Quicken onto your computer you will periodically be advised by Quicken to take "updates" to fix known "bugs" in the software. Similarly, you will load the EHR software onto the server in your office and physically download any updates to fix "bugs" that the vendor discovers and fixes.

Microsoft periodically advises you to take security updates on your home computer. Similarly, the EHR server will need to take periodic updates from Microsoft.

You may later decide to upgrade Quicken to its latest version, and then purchase and install the Quicken upgrade on your computer. Similarly, you will want to upgrade your EHR software periodically, usually every 12-18 months.

You may decide in the future to purchase a new home computer that is faster; you will have to then load the Quicken software onto that new computer and transfer all of your old Quicken data to the new computer. Similarly, you will need to periodically replace the EHR server with a newer one that is faster, stronger and/or meets future recommended requirements of the EHR software. And make sure your data gets transferred as well.

The web-based model is gaining popularity. In this model the EHR software is located on a server at a remote location designated and hosted by the EHR vendor. The physician and staff access the EHR through the Internet on computer devices in the office. This is analogous to online banking that you access on your home computer and use to pay your bills online (instead of using Quicken). Using this analogy:

You will not physically have to take updates because the bank will update the software themselves

Microsoft will not ask you to take Microsoft security updates to the online banking server because the bank hosts the server and will do that themselves

When there is an upgrade to the online banking software, you do not have to purchase and physically load that software on your computer because the bank does that on their server that you are simply accessing.

If the online banking server is too slow you will not have to purchase a new server, the bank will do that (if enough customers complain)...and they will migrate your data over to that new server)

Here is a comparison chart for these two EHR models:

Personally, the business side of me is strongly averse to allowing a 3rd party vendor to take care of the “heart and soul” of my practice (i.e. the revenue dollars and the clinical data). Hence, in private practice I would strongly favor keeping the server in-house. However, the clinic I currently work at is a small part of a large academic institution. For our ambulatory EMR I am leaning toward recommending a web-based model. The presence of an institutional IT Department whose primary purpose is to support the education of thousands of students, not to understand and dedicate the resources needed to provide a high level of clinical IT support required for a clinician using an EHR. And I know who is most likely to get trumped down the road when conflicting priorities arise!

On April 15th President Obama signed into law legislation that allows the Department of Health and Human Services (HHS) to include physicians who treat patients in hospital-based outpatient clinics among the physicians eligible for “Meaningful Use” incentive payments. These incentives are authorized by the HITECH Act portion of the 2009 American Recovery and Reinvestment Act (ARRA). Under ARRA, “hospital-based physicians” are not eligible for health IT incentive payments because they depend “substantially” on a hospital’s “facilities and equipment, including qualified electronic health records”. The new legislation clarifies the definition of “hospital-based” so that it may include physicians working in hospital outpatient clinics as opposed to the inpatient units, surgery suites or emergency departments.

As I wrote in “Academic Physician Incentives Needed to Catalyze White Coat-Driven Transformation of Medical Practice Using Health IT”, it appeared that the original intent of ARRA eligibility was misinterpreted by HHS. The new clarifying language resolves this issue.

The new bill’s clarifying language:

"SEC. 6. EHR CLARIFICATION. (a) QUALIFICATION FOR CLINIC-BASED PHYSICIANS.— (1) MEDICARE.—Section 1848(o)(1)(C)(ii) of the Social Security Act (42 U.S.C. 1395w– 4(o)(1)(C)(ii)) is amended by striking ‘‘setting (whether inpatient or outpatient)’’ and inserting ‘‘in- patient or emergency room setting’’. (2) MEDICAID.—Section 1903(t)(3)(D) of the Social Security Act (42 U.S.C. 1396b(t)(3)(D)) is amended by striking ‘‘setting (whether inpatient or outpatient)’’ and inserting ‘‘inpatient or emergency room setting’’. (b) EFFECTIVE DATE.—The amendments made by 15 subsection (a) shall be effective as if included in the enact- 16 ment of the HITECH Act (included in the American Re- 17 covery and Reinvestment Act of 2009 (Public Law 111– 18 5)). (c) IMPLEMENTATION.—Notwithstanding any other 20 provision of law, the Secretary of Health and Human 21 Services may implement the amendments made by this 22 section by program instruction or otherwise."

So, the change in section 1848 looks like this:

‘‘ (C) NON-APPLICATION TO HOSPITAL-BASED ELIGIBLE PROFESSIONALS.— ‘‘(i) IN GENERAL.—No incentive payment may be made under this paragraph in the case of a hospital-based eligible professional. H. R. 1—355 ‘‘(ii) HOSPITAL-BASED ELIGIBLE PROFESSIONAL.—For purposes of clause (i), the term ‘hospital-based eligible professional’ means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) inpatient or emergency room setting and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider. ‘‘(D) PAYMENT.—

So hospital-based physicians remain excluded from ARRA incentives, but the definition of “hospital-based” changes from those who practice in inpatient or outpatient settings to those who practice in inpatient or ER settings. This still excludes pathologists, anesthesiologists, ER physicians, hospitalists and others who see most of their patients in the ER as outpatients or as hospital inpatients. But this opens the door for HHS to interpret ARRA to mean that those who practice in hospital-based clinics using ambulatory EMRs are eligible…a setting common for many academic physicians and others who are closely associated with the ambulatory side of hospitals. This type of government response to sensible feedback brought forward by physicians and others is reassuring to see.

An enduring axiom about electronic medical record (EMR) implementations remains unchanged: “If no physician champion, then don’t implement”. The physician champion’s role in an EMR implementation is to keenly focus on strategic implementation decisions, education of colleagues on the EMR, process/work flow redesign and on the design, configuration, build and testing of the EMR.

In a June 30th Digitized Medicine blog (High Demand Persists for Chief Medical Information Officer (CMIO) and Health IT Physician Champion Roles) the evolution of the role of physician champions within health information technology (HIT) is described. In the 1970s physician IT champions typically served as clinical "subject matter experts" to ensure that clinician's needs were identified and met by IT projects. Since the 1990s the implementation of more expensive and increasingly complex clinical technologies, such as EMRs with computerized physician order entry (CPOE), has led to the need for an executive CMIO role at a majority of hospitals. As described in the blog, the CMIO role is different than the physician champion role of the 1970s. The CMIO, in fact, needs to recruit , mentor and infuse the clinical expertise of physician champions from within the organization into health IT implementations. Similarly, an office practice should identify a physician champion before selecting and implementing an EMR.

Most of the work involved in successful EMR implementations is not technical, but instead involves changes in process and work flow. The physician champion must be closely involved in the redesign of processes and work flow to ensure the changes align well with how the clinician works and thinks best. The physician champions also are the “subject matter expert” for the EMR’s clinical design, configuration and build. They work on structured documentation templates, order sets, clinical decision support tools and, most important of all, work flow redesign to optimize how the EMR design is used. The champion is a key figure for strategic decisions that need to be made during an EMR implementation. The physician champion works with colleagues to identify their unique needs. At the same time he/she educates colleagues on the value of and garners their support for standardizing their template-based documentation and orders as much as possible.

The effort needed to garner support, design the EMR and redesign processes/work flow is often underestimated. Implementations that proceed without physician champions or without enough time for the physician champion to adequately participate are more likely to encounter significant problems when the EMR “goes-live”. Examples of such problems are:

Documentation takes too much time because there are too many required answers that the physician has to enter

Documentation takes too much time because of work flow issues

Inability to easily get quality reports that were expected from the EMR, because the data is entered differently or in different places by different doctors

Pick-lists have so many choices that it frustrates the doctors

Poor template design makes it easier for clinicians to just free text; data needed for quality reports does not get entered into discrete fields that allow it to be reported on

Poor work flow redesign slows down patient flow in the office, productivity goes down

Decisions about what quality data needs to be entered in the EMR and standardization over where it gets entered are needed before even designing templates. Limiting the amount of “required fields” to these pre-determined data needs helps prevent documentation templates that are to elaborate to enter data quickly. This is important for the physician champion to drive because physicians generally expect to be able to capture quality data, produce quality reports and exchange information with registries or other health information exchange entities in their area once they have an EMR. These reports and registries are tools physicians expect from EMRs to help them improve population care.

Capturing and reporting on quality data will be required to qualify for “meaningful use” incentive payments for physicians using EMRs (under the ARRA/Stimulus package) most likely starting in 2013. The physician champion will have a key role helping the practice qualify for these incentive payments as “meaningful users”.

The physician champion has strategic roles and post-implementation roles as well. The physician champion will be a key participant in strategic decisions that the practice will have to make during the EMR implementation, including the go-live strategy ("big bang" vs. phased in) and what to do with the current paper charts or old EMR data. Post-implementation the physician champion helps optimize and maintain templates, order sets, decision support rules and other EMR tools. He/she should be the main point of contact with the EMR vendor and manage the timing and scope of future updates and upgrades to the EMR.

The importance of strong physician leadership is stressed in much of the EMR implementation literature. The following characteristics help this lead physician be effective:

Well-respected as a clinician

Strong interpersonal skills

Ability to “makes things happen”

Teaching mentality (a typical trait of most physicians)

Strong negotiating skills

Commitment to successful EHR implementation

Ability to sell EMR benefits to other physicians and office staff

Sets realistic expectations

It should be noted that although an interest in computers is helpful, technical skills are really not needed for this role. Much more important than technical proficiency is a willingness to learn and teach.

There is one final caveat based on personal experience that this author would like to share. Unless it is a small 1-3 doctor practice, the physician who is the designated EMR physician champion should not be the individual who develops, monitors and coordincates all of the tasks of the EMR implementation project plans. This is discussed further in "EMR Selection: Project Team, Project Manager and Decision Making". The physician champion’s role is to keenly focus strategic implementation activities, process/work flow redesign and on the design, configuration, build and testing of the EMR. Larger practices should consider compensating the champion for the time and effort required to successfully accomplish these tasks.

Physicians with health information technology (HIT) implementation experience are in high demand for a variety of roles in organizations that are implementing clinical IT systems such as electronic medical records (EMRs). The roles and responsibilities of these physicians has been evolving and growing. IT physicians in the early 1970s typically served as clinical "subject matter experts" to ensure that clinician's needs were identified and met by IT projects. In the 1990s the need for IT physicians increased as more hospitals implemented clinical IT systems. Throughout the 1990s a series of studies on the high prevalence of medication errors and the ability of HIT tools to reduce these errors culminated in the 1999 Institute of Medicine report, "To Err is Human". This led to external pressure on hospitals to more aggressively pursue implementations of more advanced clinical technology tools such as electronic medication administration records and computerized physician order entry (CPOE). Some of these implementations failed and others experienced sub-optimal results. Strong clinical leadership, management and oversight at the executive level became recognized as a key factors in successful implementations. The project-oriented, physician liaison role was still needed but no longer sufficient. A new generation of IT physician leaders, the Chief Medical Information Officers (CMIOs), have been added to a majority of hospital executive staffs to meet these leadership needs.

The increase in complexity of EMR implementations is due to the development of HIT products that provide more advanced functionalities and more configuration options for users to evaluate and implement. This increase in the number of functionalities available creates more work to do during the design, build and testing of the systems. More importantly, the advanced clinical IT tools such as CPOE impact a greater number of direct clinical care processes including the daily work flows for patients, nurses and doctors. These changes to processes and work flows cross over cultural boundaries in a way that organizations have not previously experienced. The transformational effort needed to overcome these cultural boundaries requires strong clinical leadership, communication skill, consensus-building skill, political maneuverability, strategic thinking, adaptablility, strong interpersonal skills and sensitivity to the organization's nuances and uniqueness. These skills describe some of the ideal characteristics of today's CMIOs.

It is important to reiterate that physician champions who are clinical "subject matter experts" remain in high demand for clinical implementations in addition to the CMIO. These physicians essentially become part of an informatics team with the CMIO. Even in small organizations it is obviously not possible for the CMIO to be the subject matter expert for every clinician for every clinical project. The CMIO can, however, be the catalyst to get the right amount of clinician participation with the right clinical expertise into clinical IT projects. The CMIO can facilitate the redesign of hospital committee structures and roles to ensure ongoing support and governance of a new EMR. To be effective, then, the experienced CMIO manages time by differentiating between situations that require their expertise through close, detailed involvement from other situations that are best managed as a facilitator, educator or mentor.

The value of a multidisciplinary informatics team with physician, nursing and other clinical liaison members is recognized by organizations. Organizations today should therefore consider planning for a multidisciplinary informatics team not just for their initial major clinical implementations, but also for ongoing optimization and support of these expensive systems. This group is the source for clinical "subject matter expertise" during IT implementations. After the implementation this group of clinicians becomes an invaluable resource for the continual optimization and support of clinical technologies. Some members, such as the physician champions, will not need to spend as much time with the informatics team post-implementation, but their experience and expertise will be tapped into. Some hospitals have decided to attract physicians to this role by creating an inpatient Medical Director for the EMR / Computerized Physician Order Entry (CPOE) and an outpatient Medical Director of Ambulatory EMRs for their physician offices. Some are full-time positions and others are part-time, dependent on the size of the organization, and they work closely with or report to the CMIO.

The early physician IT champion role of the 1970s evolved into an executive level CMIO role as clinical technologies became more advanced, more costly and more complex to implement. CMIO positions have subsequently become common within hospital organizations. Physician champions, however, also remain in demand as clinical "subject matter experts" for their clinical IT systems. As organizations continue to implement, upgrade, optimize and support their expensive clinical IT systems, CMIOs and clinical IT liaisons including physicians, nurses, lab technicians and pharmacists will remain in high demand.